The Utah Medicaid program provides pregnancy-related coverage
for
women whose household incomes are less than or equal to 133% of the
federal
poverty level. * For women who are not otherwise eligible, Medicaid
coverage of family-planning and other services ends after the
second
calendar month following delivery. To assess whether increased
access to
family-planning services would benefit Medicaid recipients, the
interpregnancy intervals (IPIs) of Utah residents whose most recent
pregnancies were covered by Medicaid (Medicaid-recipient mothers)
were
compared with those of all other Utah resident mothers. This report
summarizes the results of that study, which indicate that
Medicaid-recipient mothers aged greater than or equal to 20 years
were at
increased risk for having short IPIs, and may therefore benefit
from
extended Medicaid coverage or other means of assuring access to
family-planning services.

Data for live-born infants of Utah resident mothers from June
30,
1996, through June 29, 1997, were matched to the Medicaid
eligibility
database by using the mother's date of birth, last name, first
name, and
middle initial. IPI was defined as the time between delivery dates
of
consecutive live-born infants minus the gestational age (1) of the
most
recent child. A short IPI was defined as an IPI of less than 12
months;
this cutoff was based on a parallel study that showed that IPIs of
less
than 12 months were associated with significantly elevated risks
for
adverse perinatal outcomes (Utah Department of Health, unpublished
data,
1998). The risk for having a short IPI was examined in relation to
maternal
Medicaid status and age, marital status, education, and
race/ethnicity. A
mother's education was categorized as age-appropriate if she had
completed
high school or the usual number of grades for her age. The
educational
status of mothers aged greater than or equal to 20 years also was
evaluated
based on the number of years of school completed (0-11, 12, 13-15,
16, and
greater than 16 years).

Of the 42,429 live-born infants of Utah resident mothers from
June 30,
1996, through June 29, 1997, 15,810 (37.3%) were ineligible for the
study
because they were first-born infants. An additional 4773 (11.2%)
infants
were excluded because the date of the previous delivery of a
live-born
infant or information for estimating gestational age were missing
on the
birth certificates.

Of the 21,846 (51.5%) infants eligible for study, 3916 (17.9%)
were
born after a short IPI (Table_1). Medicaid-recipient mothers
(22.9% of
all mothers in the study population) were nearly twice as likely as
other
mothers to have short IPIs. Young maternal age correlated strongly
with
short IPIs. Short IPIs were more common among unmarried mothers
(22.5%)
than married mothers (17.4%), and among mothers with less than
age-appropriate education (25.2%) than among those with
age-appropriate
education (17.1%). American Indian/Alaskan Native mothers and
Asian/Pacific
Islander mothers were more likely to have short IPIs than white
mothers,
and Hispanic mothers were more likely to have short IPIs than
non-Hispanic
mothers. Mothers who had either one or five or more previous
live-born
infants were more likely to have short IPIs than mothers who had
three
previous live-born children.

When stratified analyses were performed, the association
between
Medicaid status and short IPI differed by maternal age. Among
mothers aged
greater than or equal to 20 years at delivery (21,207 {97.1%} of
all
mothers studied), Medicaid recipients were more likely to have
short IPIs
than others (relative risk {RR}=1.7, 95% confidence interval
{CI}=1.6-1.8).
However, among mothers aged 15-19 years (631 {2.9%} of all
mothers), no
such association was found (RR=1.0, 95% CI=0.9-1.2).

To evaluate risk factors for having short IPIs while
simultaneously
controlling for other covariates, logistic regression analyses were
performed. Among mothers aged greater than or equal to 20 years
(Table_2), Medicaid-recipient mothers were more likely to have
short
IPIs than other mothers (odds ratio=1.6, 95% CI=1.5-1.8). Mothers
from
racial/ethnic minority groups had a higher risk for short IPI than
white
mothers. Married mothers were more likely to have short IPIs than
unmarried
mothers. The risk for short IPI was inversely correlated with
maternal age.

Editorial Note

Editorial Note: Short IPIs have been associated with an increased
risk for
adverse birth outcomes (2-5). Pregnancies that are too closely
spaced often
are unintended, which can place substantial financial and
psychologic
burdens on the mother and her family (6). The findings in this
study
indicate that Medicaid-recipient mothers aged greater than or equal
to 20
years were more likely to have short IPIs than other mothers of the
same
age. Young mothers and mothers of racial/ethnic minority groups had
increased risk for short IPIs. Utah data were unavailable to
evaluate
whether Medicaid-recipient mothers tended to have a shorter
duration of
breastfeeding or greater desire to build their families quickly
than other
mothers -- two factors that may contribute to short IPIs. Utah
women whose
deliveries were covered by Medicaid, most of whom lose Medicaid
coverage
shortly after delivery, may have less access to family-planning
services.
Improving these women's access to family-planning services might
help them
prevent unintended pregnancies, and improve birth outcomes. Access
could be
improved by removing financial barriers through extending Medicaid
coverage
for all women after a Medicaid-covered delivery, or through
increasing
availability of family-planning services for low-income women. In
Utah, 74
publicly funded clinics provide family-planning services to
low-income
women. However, only 26% of all such women are served; Utah ranks
49th
among all states for providing access to family-planning services
(7).

The higher risk for having short IPIs among mothers from
racial/ethnic
minority groups may have been due to cultural or socioeconomic
differences
or to unequal access to health care. An example of such a factor
was
observed in one study that found the length of breastfeeding
differed by
race (8).

Because the sociodemographic characteristics of the Utah
population
are different from those of other states, caution should be used in
generalizing the results of this study. In addition, the findings
of this
study are subject to at least three methodologic limitations.
First,
Medicaid status was based on the most recent pregnancy. The number
of women
in the study population whose Medicaid status had changed since the
previous pregnancy was unknown; an implicit assumption has been
made that
mothers on Medicaid for the most recent pregnancy were on Medicaid
for the
previous one. Second, this study included women whose Medicaid
eligibility
was independent of pregnancy and those who were eligible only
because they
were pregnant and met the program's income requirements. Finally,
the
retrospective approach of this study may have overestimated the
risk for
having short IPIs among young women, although such bias is unlikely
to
account for much of the elevated risk among those women.

In Utah, extending Medicaid coverage of family-planning
services and
improving use of family-planning programs should be considered to
help
low-income women prevent unintended pregnancies and improve birth
outcomes.
Public health programs for preventing short IPIs also should target
young
mothers regardless of their Medicaid-eligibility status. The
analysis
described in this report may be repeated to monitor the success of
efforts
to improve reproductive health of women in Utah.

Poverty statistics are based on definitions developed by the
Social
Security Administration in 1964 (which subsequently were modified
by
federal interagency committees in 1969 and 1980) and prescribed by
the
Office of Management and Budget as the standard to be used by
federal
agencies for statistical purposes.

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